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Building BUILDING Permit No..
Inspections RESIDENTIAL APPLICATION xe�ei�ed By�
7b3-572-3604 CITY OF FRIDLEY Dat��1:�AY �,
763-502-4977 FAX EFFECTivE �-i-ZOio
DATE�� - Q% � YO[JR E-MAIL ADDRESS
SITE ADDRESS � �' �j/y� CX.p�I.G � �
THIS APPLICANT IS: ❑ OWNER �CONTRACTOR
PROPERTY OWNER/ N��: �
TENANT �DRESS: G�CITY ~ STATE i'16�IP T
PHONE: � iD �"� S I' 3���
CONTRACTOR N�tE:
SUBMTT A COPY OF STATE LICENSE # `�.� C% l� (� a-Ct (, EXP DATE ,7�' � I'��
YOUR STATE LICENSE `�
AND CERTIFiCATE OF �D�,ss: `_3U� SUJ ��� ��. S /C�crrY^f��I�s�,, 'TE I�?�LIP s-� oa
INSURANCE PHONE - N- U�� FAX I— �l �L��%W
PROPERTY TYPE ❑ SINGLE FAMILY/NEW CONSTRUCTION SIZE
❑ TWO FAMILY/NEW CONSTRUCTION STORIES
PERMIT TYPE � �DITION ❑ GARAGE/SHED ��VINDOWS
❑ BASEMENT FRIISH ❑ ROOF ❑ DRAIN TILE
0 DECK ❑ SIDING ❑ OTHER
❑ SWIlvIMING POOL
TYPE OF WORK: ❑ NEW HOME CONSTRUCTION ❑ ADDITION
❑ MAINTENANCE/REPAIR ❑ REMODELTNG
DESCRIBE WORK BEING DONE: (/I�t_ L�
SIZE OF IMPROVEMENT LENGTH H HEIGHT S FT
ROOFING ❑ HOUSE ONLY BASEMENT REMODELING SUBMIT:
NUMBER OF SQUARES ❑ HOUSE & GARAGE
1. ExistingFloor Plan
GARAGES ❑ ATTACAED GARAGE 2. Proposed floor plan
PROPOSED SIZE: ❑ DETACHED GARAGE 3. List of structural members to be used
PROPOSED HEIGHT:
SIDING FORNEW CONSTRUCTION INCLUDING DECKS,
❑ Vinyl ❑Soffit ADDITIONS. & PORCHES SUBMTT:
❑ Aluminum ❑ Trim 1. Site Plan/Survey showing the existing siructures
O Other ❑ Fascia and proposed project.
2. Two sets of construction plans
WINDOWS 3. Energy Calculations
IN EXISTING OPENINGS Yes ❑No LOCATION OF WINDOWS FOR WINDOWS - PROVIDE U-VALUE AND
OR FOR NEW OPENINGS�ESCRIBE SIZE OF MANUFACTURE STICKER ON WINDOW.
OPENING CHANGES &
TYPE OF WINDOW TO BE INSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASF.D ON VALUATION,INCLUDING THE COST �F LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE) .
TOTAL JOB VALUATION $ , OCCUPANCY TYPE
Pernut Fee $ See Back Page for Fee Schedule
Plan Review $ 65% of Building Permit Fee
Fire Surcharge $ .001 times the total job valuatiori
Surcharge $ .0005 x Permit Valuation Minimum $5.00
License Surchazge $ $5.00 (State LicensedResidential Contractors)
SAC Charge $ $2100 per SAC Unit (Plans to MWCC for determination)
Curb Cut Escrow $ ft+ 6 ft= ft x$24 =$
Erosion Control $ $450 Conservation Plan Review
Park Fee $ Fee Determined by Engineering
Sewer Main Charge $ Agreement necessary O Non Necessary O
--- �a1-IIue— ---_- �_ + __ Make checks paxable to: Citv of Fridlev Attach Stipulations
TI�iIS IS AN APPLICATION FOR A PERMIT-NOT VALID LTNTIL PROCESSED
I hereby apply for a building permit and I aclrnowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances an codes of e City of Fridley and with the Minnesota Construction Codes; that I understand this is not a
permit but only an application for a it d work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of otic 'ch uires r vi w and approval of p� �. yj DA� �_ �_1 �
SIGNATURE OF APPLICANT PRINT NAME t�1►rl � E�Y { Cj �
APPROVAL INSPECTOR SIGNATURE